Please enjoy this post from the archives dated November 23, 2011
Faculty Peer Reviewed
The goal of public health is to prevent or minimize disease and injury on a population level. How to achieve this end has changed over time, though. In previous decades, communicable diseases posed the greatest health risks. Consequently, public health officials used the tools of isolation, quarantine, and (forced) vaccination to combat these threats. Today, however, the major causes of morbidity and mortality are chronic conditions, many of which are thought to be due to lifestyle behaviors. Consider obesity, premature heart disease, and tobacco use as examples. The traditional tools of public health fail to address these newer threats to human welfare.
Understanding this limitation, the public health community has undergone a paradigmatic shift, moving away from contagion control to focus instead on these modifiable risk factors. Using mass media, public health campaigns now seek to change people’s behavior to forestall bad health outcomes. Within this new framework, these campaigns often use fear as a motivating force. The question thus arises, is fear an appropriate tool for a public health agency to use to effect behavioral change and advance a health agenda?
In order to examine the use of fear-based advertising in public health campaigns, one must define what advertising is exactly. Essentially, advertising is the use of media to persuade people to consume a product or service. When a government agency or other public interest group uses advertising to deliver its message for societal betterment, this becomes social marketing. Social theorists have described this as “the application of commercial marketing technologies…to influence [the] voluntary behavior of target audiences in order to improve their personal welfare and that of their society.” Furthermore, social marketing borrows the key feature of commercial marketing, that of the “individual-as-consumer.” Influencing that individual’s consumption of health information and the adoption of specific behaviors through social marketing can improve social good overall.
Fear-based advertising is a specific type of social marketing that employs scare tactics or other anxiety-producing mechanisms to highlight the dangers of engaging (or not engaging) in a certain practice, like smoking or drunken driving. This strategy can be a cost-effective way to reach a wide audience, as the New York City Department of Health and Mental Hygiene has done. The Department has released several graphic and hard-hitting ads in recent years attacking smoking, encouraging influenza vaccinations, and warning of the dangers of sugar-sweetened beverages. Regarding the “Smoking Kills” poster campaign from the spring of 2009 which shows graphic depictions of smoking-induced lung cancer, NYC Health Commissioner Thomas Farley argued that “[s]mokers who are more aware of health risks are more likely to quit…[and having warnings] be more graphic makes [people] more aware of health risks.”
Not surprisingly, fear-based advertising is not without its discontents. Different countries have different tolerances for the amount of fear and negativity that public health agencies are allowed to use. Australia, the United States, the United Kingdom, Quebec, and several nations in Southeast Asia have used fear and gore in combating drunken driving and smoking. Cigarette packs in Malaysia not only explicitly warn the consumer that smoking will cause cancer, but they also show graphic photos of neck and lung tumors. Anti-drunken driving commercials in Australia show the horrendous aftermaths of car crashes. On the other hand, nations like Canada (the English-speaking provinces) and Holland are far less likely to use this tactic, instead relying on humor and gain-framed messaging. Whether one strategy works more than the other has been the subject of much debate and research, with both sides claiming victory.
If this media tactic is controversial and potentially ethically problematic, why do public health agencies use it? Does it really work, and if so, how? Numerous studies have examined the effectiveness of negative ads on smoking cessation and drunken driving. For example, when the Massachusetts Tobacco Control Program launched a series of anti-smoking ads on television, one study found that viewers responded much more strongly to the negative ads that evoked fear and sadness than other ads without fear appeals. The study participants felt that those ads would make them more likely to stop smoking. Similar results were found in other American and Australian studies.
That these fear-based ads can work is not the issue, but rather, how they work. Some argue that the shock tactics used by these ads need to be intense to get people’s attention, in order to cut through the chatter of everyday life. We live in a time when information is all around us, and each message is fighting for the viewer’s limited attention. Consequently, the more graphic and visually jarring messages are more likely to get noticed. Also, convincing people to make (unwanted) behavioral changes may require the use of forceful language and strong motivators.
Despite the laudable public health goals of limiting morbidity and mortality, doing so with fear remains troublesome. This debate can be examined from two opposing ethical frameworks: deontology and teleology. Whereas deontology is more concerned with absolute moral foundations, teleology focuses on outcomes. Whether one uses one approach or the other governs how one would view the acceptability of fear-based advertising.
The deontologist opinion holds that all public health measures must be grounded in a priori moral certainties. Invoking the principle of beneficence, a deontologist would “reject the use of fear appeals outright on the grounds that, regardless of the ultimate societal gains, it is wrong to engender anxiety and distress.” The essential feature of fear-based advertising is this very anxiety and distress that deontology would not allow. For example, the NYC DOHMH “Smoking Kills” ads could arguably invoke incredible guilt and feelings of personal mortality in the smoker. Of course, seeing these images may encourage the smoker to quit, but the attack on his mental well-being would be unsupportable.
On the other hand, the teleologist would posit that the ends can justify the means, if those ends are socially beneficial. Recognizing that any intervention can have both positive and negative consequences, the teleologic goal is to have a net positive result. The measurable increase in the public’s health status can take precedent over any anxiety and social distress that an intervention could create. Using the language of utilitarianism, “[c]hoices are deemed ethical if they result in the greatest good for the greatest number of people.” If a hundred people decide to stop smoking after seeing that same cancerous poster, then the intervention is both successful and ethical, despite the personal worries that that one individual may have felt.
Reconciling these two disparate paradigms is by no means easy, or even possible. Population-based disciplines, like public health, are fundamentally consequentialist, and they subsume the thoughts and wishes of the individual to the needs of the populace. This form of paternalism differs, though, from the strict paternalism that many of us expect, like mandatory immunizations or workplace safety standards. However, if the idea of paternalism centers on the use of state power and authority to guide the behavior of individuals, then it becomes quite clear that the state’s use of fear-based advertising is frankly paternalistic.
But we must ask ourselves, who really stands to benefit with the use of these ads? Is it the individual viewer, the state, or both? The sole beneficiary cannot be the state, or even the general population. But, if the individual stands to make significant gains in health, then it becomes difficult not to want to use these scare tactics. Although utilitarian ethics would take into consideration the broader social betterment created by the improvement in individual health, the rights of the individual cannot be wholly ignored.
A crucial caveat of this libertarian critique is that these fear-based ads must be imposed upon the viewer, without the viewer’s consent. John Stuart Mill, a significant advocate of 19th century political and social libertarianism, was explicit in his belief that the state cannot enforce its will on the governed without the permission of the governed. Furthermore, one could posit that the state’s use of the media to carry its message into the home could be a form of intrusion. A family at home watching television does not have control over the commercials and ads that appear on their TV screen. This family cannot call the local cable provider and “opt-out” of distressing public health advertisements.
On the surface, this example may seem clear cut. This family has not given their consent to the state to receive these messages in their home. Although they have not given their explicit consent, the simple act of turning on the television or opening a newspaper gives implied consent. The public should expect a risk of seeing distressing images in the media. Much like driving, when one gets behind the wheel of a car, one is implicitly taking on the risk of having an auto accident. Similarly, when one turns on the television, there is the risk of seeing a graphic health message that the viewer accepts. And perhaps more relevant, a media viewer always has the option to remove himself from the situation by simply changing the channel or looking away from the poster. It could be claimed that the individual is by no means held hostage by the public health message, and the unsolicited advice could easily be avoided. Yet, ads are purposely designed not to be easily shunned.
Furthermore, the actual content of the ad may matter more than its emotional style. Fear-based ads that solely rely on a haunting message may scare the viewer, but they do not necessarily lead to results. “Messages…which do induce fear, but whose behaviour [sic] recommendations are insufficiently feasible…have the strongest opposite effects in terms of rejection of and resistance to the message.” The key component should be to provide advice on how not to succumb to the health threat. This advice is necessary to provide the viewer with the self-efficacy needed to effect necessary change and to overcome the fear engendered by the ad.
Even more troublesome is the risk that these ads run of victim blaming. Fear-based ads must be incredibly cautious about walking the fine line between warning about health dangers and blaming those already affected by those dangers. For example, safe-sex ads that encourage people to use condoms to prevent the spread of HIV could potentially stigmatize people living with HIV. These ads could imply that those persons infected with HIV were not cautious enough or careful enough to avoid infection. If only they had followed the advice of the public health community, they would have remained HIV-free.
On the other hand, fear-based ads can actually use the victim as their spokesperson. In 2008, the NYC Health Department ran an anti-smoking ad which featured a Bronx woman with Buerger’s disease. This particular condition predisposes patients to peripheral vascular disease which can lead to finger and toe amputations. This risk is multiplicatively increased by smoking. In these television ads, the woman directly faces the viewer, shows her gnarled hands, and tells us that she has undergone twenty amputations because of her smoking. The last line of the ad is, “I don’t smoke anymore.” Far from blaming this woman for the years of medical complications that she has endured because of her smoking, this frankly shocking ad actually attempts to empower this individual to help other smokers to quit.
Similar to victim-blaming, fear-based ads may target already politically and socially disenfranchised communities. Health promotions, unfortunately, tend to produce social inequities. People of higher socioeconomic statuses usually adopt healthy behaviors before those of lower SES. Research on the decades of anti-smoking educational campaigns has shown that the biggest declines in smoking rates have occurred among the wealthy and middle classes while the working classes continue to bear the burden to tobacco addiction. For anti-smoking advertisements, to be more effective, they would logically have to be directed at those communities where smoking rates are high. Targeted selection could, however, stigmatize this class of people. These ads are trying to effect behavioral change in a community already lacking in resources to sustain that change. Inundating this community with fear about their lifestyle choices, coupled with a lack of means to make fundamental changes and improvement, is far from ethical. Doing so simply marginalizes this community further and it may induce different degrees of medical nihilism.
Another drawback of using fear-based advertising, especially for targeted communities, is defining specifically who is at risk. Although particular ads may highlight the risk in defined populations, these ads may allow people who do not fit these descriptions to delude themselves into thinking that they are not at risk. This would be an extremely dangerous misreading of the public health message and nullify any societal gains made by these ads.
To get around this problem, some ads try to avoid targeting and emphasize the universality of risk. This also avoids the ethical issues of implying that one particular group of people is more susceptible than another. One Israeli ad from the late 1990s showed two women, one was an older grandmotherly woman wearing an ankle-length skirt and the other was a young woman wearing heels and fishnet stockings. The caption read, “AIDS makes no distinction among people.” Rather than focusing on young, sexually active adults, the Israeli Task Force chose a more ethically palatable approach to show that everyone is potentially at risk.
Also, fear-based advertising is subject to the law of diminishing returns. With each viewing of a negative ad, the viewer experiences less shock and emotional appeal. Since fear-based ads have been around for several decades now, with varying degrees of intensity, one must question whether the fear appeals today still work with the same efficacy that they did in times past. In 2004, one research group in Australia and New Zealand studied this phenomenon with regards to fear-based advertising in preventing reckless driving. They found that “participants indicated growing tired of such negative appeals and feeling numbed to ‘shock tactic advertising.’” This was disconcerting to the researchers because the loss of the ads’ “persuasive ability” basically rendered the ads impotent.
To grab the same level of attention, subsequent ads must be more shocking and jarring than the previous. “[W]ith high-threat advertising…there is a need to intensify the threat on each subsequent occasion to produce the same level of fear.” If one has to keep increasing this intensity, where does one stop? Would it be acceptable to show a man dying from lung cancer to promote smoking cessation? Should health and transportation departments show footage of actual car crashes and fatalities to reduce drunken driving?
Many would argue against such drastic measures, even in the name of public health and safety. Bombarding citizens with these disturbing images of death and destruction could easily seem as lacking any ethical foundation, even from a utilitarian perspective, as the effects of such graphic ads would be far too unsettling to justify.
Furthermore, such graphic advertisements could damage the reputation of the public health service. If the agency frequently employs scare tactics, the public could come to consider it a supplier of fear rather than health. “The [agency] could [then] become irretrievably linked with the negative and the threatening.” This would erode the necessary trust that the public must have in its health authorities and hamper future endeavors, even those not based on fear.
Regardless, negative advertising may become a permanent fixture of public health campaigns. Is there a solution that addresses both the ethical and practical complications of this tactic? Can fear-based ads be used in a way that does not infringe upon personal liberties and still promotes the general good?
First, public health officials need to know to whom these types of ads would appeal. Not all people are equally affected by fear appeals and not all want to view them. Selective distribution to those groups of people would limit the impact of anxiety on those who would not benefit from these ads. Focus group analysis would be helpful here. Although difficult to accomplish, this approach is still worthy of consideration in public policy planning.
Also, instead of traditional targeting based on demographics, like age, race, or SES, a new type of targeting could be used to focus on locations where unhealthy behaviors happen. In New York City, we recently started point-of-sale anti-smoking ads. These striking posters specifically target those people buying cigarettes instead of the general public. This style would take much more forethought and planning, but it would help to limit the exposure of the ads’ infringement only to those most likely to benefit from their message.
Furthermore, to avoid the Millian critique of unjustified paternalism, negative ads could use a harm-to-others appeal. Instead of focusing on the harmful health effects to the individual, the ads could instead discuss the effects on others around that individual. Secondhand smoke around children is a classic example. This technique would have a more solid ethical foundation than the simple harm-to-self approach.
Finally, we must ask ourselves if we are better off with this form of health promotion or whether other, more positive, techniques are more desirable. In designing a health promotion campaign, one has to both focus on the target goal and the steps taken to reach that goal. Unfortunately, there is no formula for weighing the relative importance of intangible factors like anxiety, fear, and self-efficacy that can be crucial to a successful media strategy. However, we do know that these ads can work when used appropriately, but that they also have numerous disadvantages and can potentially backfire. Regardless of the ethical framework that one uses to examine the concept of fear-based advertising, the question of whether the use of fear is acceptable cannot be readily answered. Without a univocal ethical solution to this controversial tactic to guide policymakers, public health officials must rely on best evidence of efficacy and on their professional and moral judgment in order to use the mass media as an educational tool in promoting health to the benefit of individuals and the community.
Commentary by Antonella Surbone, MD, Ethics Editor, Clinical Correlations
The piece on “Ethical Considerations on the Use of Fear in Public Health Campaigns” offers an in-depth analysis of the ethical pro and cons of fear-based public health campaigns seeking to change people’s behaviors and life styles to prevent or limit morbidity and mortality. In reading this informative and interesting piece, I believe we may also reflect on cultural differences in communication styles, symbols and metaphoric meaning of words. Even when a fear-evoking image may be deemed appropriate by some or most people in a western context, the same image may be considered disrespectful in a different cultural context. Furthermore, it may also not elicit the same feelings and/or reactions in those who see it. For example, the war language often used in speaking about cancer prevention and treatment may not be suitable for all cancer patients and their families or communities for whom cancer itself can be a serious illness, or a metaphor of death or of shame and guilt.
Dr. Ishmeal Bradley is a Section Editor, Clinical Correlations
Peer reviewed by Antonella Surbone, MD, Ethics Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
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